Friday, December 01, 2006

Auto repairs, alternative medicine and fiduciary duty

I went and got my car winterized the other day, just in time for the impending meteorological catastrophe. They told me I needed, among other things, a radiator flush. They took me through the steps in making the “diagnosis”, dutifully showing me their findings, but it didn’t really matter. Mechanically disinclined not-so-smart consumer that I am I ultimately had to take their word for it. It was one of those reputable quick-lube chains, trusted by housewives and little old ladies, with mechanics who were certified. I didn’t know exactly what that meant, but I figured it was something significant. It probably meant they had a certain level of expertise and could reasonably be expected to apply that expertise honestly to my service needs. In other words I had reason to trust them. I was entitled to certain assumptions about the service I would get, assumptions I couldn’t make if I had taken my car to, for example, the Griner Brothers’ Garage, where it’s strictly caveat emptor.

And so it is with medicine. I know it’s dangerous to compare medicine with auto repair, but there may be a useful analogy here concerning the responsibility of a person in a position of trust (and we’ll restrict the comparison to just that). In medicine we sometimes call it fiduciary duty. Our particular fiduciary duty to patients is to be and do what all those certifications and accreditations lead them to expect. They expect expertise, and for that expertise to be applied honestly. Moreover, the general public perception of that expertise, at least for us in mainstream medicine, is that it’s based on science. Most patients, when offered a particular treatment, believe that. Lacking any desire or ability to verify it independently they simply trust that it’s so. This presents an ethical problem when unscientific treatment methods are offered to patients (call it alternative medicine, call it what you will; I think Orac’s term “woo” should serve our purpose here as well as any other).

Now, in order to really parse the ethics of woo I would propose two broad contextual categories: stand-alone woo and integrated woo. Here are my definitions. Stand alone woo: woo which is offered by a clinic or institution as its major method of treatment. Integrated woo: woo which is promoted by “mainstream medicine”, accounts for a relatively small fraction of total treatment offerings and is more likely to be disguised as science.

This definition is somewhat imprecise and there are fuzzy areas. Some stand-alone woo providers, for example, have “MD” after their names and purport to “integrate” the best of woo with the best of conventional medicine. Nevertheless I place such institutions in the category of stand-alone woo because they major in woo, and that fact is usually patently clear to patient-shoppers. The average consumers know it when they see it.

Integrated woo presents the more serious ethical problem because the mainstream institutions (like, I’m embarrassed to say, my beloved medical alma mater Vanderbilt) are putting their good names, their certifications and accreditations, behind the woo they promote. Patients come, most of them anyway, expecting scientifically based treatment, and may be none the wiser when offered woo. After all, mainstream science-based providers wouldn’t promote something unscientific, would they? Why should patients expect them to? When they receive treatment based on an eclectic, mystical world view it's disguised, implicitly or explicitly, as science. The woo is more insidious, more subtle, which is why it’s all the more egregious. Patients are flat out being deceived unless, as recently suggested by anti-pseudoscience warrior Wallace Sampson, they receive explicit informed consent about the nature of the method being offered.

I have less of an ethical problem with the stand-alone woo providers. For one thing, maybe they don’t know any better. I’m convinced that they (many of them anyway) truly believe in what they do, are trying to make an honest living and have a heart for helping patients. (This is in contrast to the mainstream hospitals and medical schools which know better, or should know better). Secondly, the stand-alones, many of whom are openly dismissive about western science, aren’t nearly as pretentious about any scientific underpinnings as are the mainstream folks. As a consumer you know what you’re getting with the stand-alones. It’s caveat emptor, like going to the Griner brothers’ garage.

So, I say let the stand-alones compete in the open market place of ideas. To those in the mainstream for whom this shoe of integrated woo fits, clean it up. To medical school faculty who remain silent while the largest and most influential activist group of medical students on your campus promotes chelation for everything under the sun that ails a person, wake up. To physicians who care about evidence based medicine, if you see woo creeping into your hospital or clinic, speak out. To those in the mainstream who lend your good name to the promotion of quackery in your institutions, STOP IT! It’s unethical. It’s a violation of fiduciary duty.

6 comments:

I could not agree more. As a fertility specialist I see patients ever week on a multitude of "alternative medications" and supplements. They spend thousands of dollars for huge claimed but untested results. mainstream doctors too often now are advocating the use of these and dispensing them as well. There is so little actual testing so I tell them remember if it works it's got an active drug ingredient-- that means you can get too much or too little and that it must be used for precisely the correct diagnosis and will interact with other meds.

Look here for a post in the comments I discuss a conversation I had with someone I met who imports these things.

I think that mainstream hospitals are offering alternative medicine treatments for many reasons. First of all, they realize that people are turning away from allopathic medicine because they perceive it as cold, unfeeling, and focused on profits. Allopathic medicine can physically treat the disease but all too often leaves the patient feeling sicker than they were before the treatment, stressed out, and angry at an uncaring medical system. Alternative medicine, whether it works or not (I personally believe that some is great and some is quackery) is focused on treating the whole person, mind, body, and soul. We have plenty of scientific evidence that stress is bad for the immune system and overall wellness, and much of alternative medicine is geared towards lowering stress and helping the body heal itself. To me, combining them is a GREAT idea, because it balances the physical effectiveness of traditional medicine with the mood and immune-boosting qualities of alternatives. In the case of herbal treatments, it also allows doctors to keep better track of what supplements a patient is taking, and even collect data on outcomes to determine whether, for example, women with breast cancer who take Herb Z along with chemo live longer than women who just do chemo. Complementary medical programs provide the opportunity to do the very scientific research you say you want.

As a first time reader - it aseems to me your conversations are not distinguishing between therapeutic activites that have been shown to have some positive effects (prayer, distance healing (search W. Jones, Dean Radin)) and those that are scientifically/ materialistically understood. Until you make this distinction in your conversation, it seems to me your conversing 'pseudo-intelligently'. My experience is that much of what your are calling "woo" has been shown to be effective (it helps people); but it has not been understood (causal pathways clarified) - sort of like aspirin.With interst.chj

Personally, I turn to alternative medicines or "woo" as you call it. I like taking a more natural approach before trying western medicine practices. To help me figure out what's really right for me, I want to read Dr. Dean Ornish's new book the "Spectrum". He provides you tools to customize a way of eating, managing stress, and exercising that is based on your own desires, needs, and genetic predispositions. Hopefully this will help me figure out what's best for me... Here's a link to an interesting discussion about it: http://www.wellsphere.com/viewGroup.s?id=110918

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